Guidelines for Submission - Home Page - IPHA · Web viewFor further information, technical assistance, and to submit your completed application, contact: Krissy Roseberry. IPHA Assistant

Application for Hosting an AmeriCorps Member

with Illinois Public Health Association

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GUIDELINES FOR SUBMISSION

COMPLETED APPLICATION CHECKLISTCompleted cover sheet (all pages including signed certifications and assurances).All application questions are responded to completely and individually.Detailed and accurate position description.Send a signed copy of the application via e-mail by 5:00 pm January 3, 2019.Send an original copy of the application in Microsoft Word via e-mail by 5:00 pm January 3, 2019.

PROGRAM TIMELINEHost Site Application Due to IPHA January 3, 2019

Notification of Status January 7, 2019

Member Recruitment January 2019

Candidate Interviews and Selection January 2019

Member Positions Offered January 28 – February 1, 2019

Host Site Organization Orientation/Training (Required for All Host Site Supervisors)

Late January/Early February 2019 (date TBD)

Members Attend IPHA AmeriCorps Program Orientation February 11 – 12, 2019

Members’ First Day at Host Site Organization February 13, 2019

SUBMISSION

For further information, technical assistance, and to submit your completed application, contact:

Krissy RoseberryIPHA Assistant Director /AmeriCorps Program Director223 South Third StreetSpringfield, IL 62701Phone: 217-553-5246Fax: 217-522-5689E-mail: [email protected]

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ILLINOIS PUBLIC HEALTH ASSOCIATION AMERICORPS PROGRAM HOST SITE APPLICATION COVERSHEET

CONTACT INFORMATION FOR APPLICANT ORGANIZATIONName of Organization:Address:City, State, Zip Code (include 4 digit zip code extension):Executive Director/Administrator Name: Title:Phone Number: Fax Number:E-mail:

CONTACT INFORMATION FOR DESIGNATED IPHA AMERICORPS PROGRAMHOST SITE SUPERVISORAddress:City, State, Zip Code (include 4 digit zip code extension):Name: Title:Phone Number: Fax Number:E-mail:

NAME AND ADDRESS OF LOCATION WHERE MEMBER(S) WILL SERVE(IF DIFFERENT FROM ORGANIZATION NAME AND ADDRESS)Location Name:Address:City, State, Zip Code (include 4 digit zip code extension):Phone Number: Fax Number:

CONTACT INFORMATION FOR INDIVIDUAL WHO SHOULD RECEIVE HOST SITECASH MATCH INVOICEName: Title:Address:City, State, Zip Code (include 4 digit zip code extension):Phone Number: Fax Number:E-mail:

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ILLINOIS PUBLIC HEALTH ASSOCIATION AMERICORPS PROGRAM HOST SITE APPLICATION COVERSHEET (CONTINUED)

1. Please indicate your organization type: Non-Profit Organization Local Health Department University Coalition Other (please specify): _________________________________________________

2. Current IPHA Affiliate? Yes No Interested in becoming an IPHA Affiliate

3. Number of members requested: One Two Other ______(Unless they are identical, a separate application needs to be submitted for each position)

4. Which of IPHA AmeriCorps’ Priority Focus Areas will your requested member address? Healthy Futures (Health Education) Disaster Preparedness Neither (please specify): _________________________________________________

5. County/counties where the service be conducted: __________________________________________

6. If applicable, have you discussed the placement of an AmeriCorps member with your union representative?

Yes No N/A

*AmeriCorps provisions require that if a member will be performing duties that are also being performed by union employees, the Host Site must provide written concurrence from the union leadership that the AmeriCorps Member may perform such duties, before a member is placed at the organization.

7. The member will have access to the following resources for service activities (check all that apply):

Telephone/Voicemail Fax machine Computer Email Internet Personal office space/desk Copy machine

8. Term of Service and Host Site Cash Match: 900 Hour Term of Service; With Contributing In-Kind: $6,040 900 Hour Term of Service; Without Contributing In-Kind: $7,840 1200 Hour Term of Service; With Contributing In-Kind: $8,050 1200 Hour Term of Service; Without Contributing In-Kind: $10,500

9. Funding for Cash Match is: Pending Secured If pending, indicate anticipated date of award: _______

10. Source of Cash Match Funding: Government: Federal State Local

Private: Local Foundation 4

Other (please specify): ________________________________

11. IPHA requires each hosting organization to provide documented, non-Federally funded in-kind contributions made in support of member activities. In-kind may include Site Supervisor time, member mileage reimbursement or other travel expenses, and member training expenses. Our organization will be able to contribute the following non-Federally funded in-kind during the program year:

Site Supervisor Time Member Mileage Reimbursement Other Member Travel Expenses Member Training Expenses

ILLINOIS PUBLIC HEALTH ASSOCIATION AMERICORPS PROGRAM HOST SITE APPLICATION COVERSHEET (CONTINUED)ACKNOWLEDGEMENTSWe understand that AmeriCorps members placed through IPHA are required to attend quarterly team trainings, participate in monthly team conference calls, and participate in three National Days of Service projects. We agree to release them from the site to participate in team meetings, trainings, and service projects. We support IPHA in its effort to provide member training and recognition events and will accommodate occasional absences of the member (with advance notice, when possible) for this purpose.

CERTIFICATIONS: DRUG-FREE WORKPLACE AND NON-DISCRIMINATION POLICIESThe legal applicant organization has an active Drug-Free Workplace Policy and an active Non-Discrimination Policy.

ASSURANCESAs the authorized representative of the applicant organization, I certify, to the best of my knowledge and belief, that our organization: Has the institutional, managerial, and financial capability (including sufficient funds to pay the Host

Site cash match) required to ensure proper planning, management, and completion of the activities described in this application.

Will comply with all applicable requirements of all other Federal laws, executive orders, regulations and policies governing this program.

Will keep such records and provide such information to IPHA, the Serve Illinois Commission, or CNCS with respect to the program as may be required for fiscal audits and program evaluation, including documentation of in-kind contributions.

Will comply with the non-displacement rules of the National and Community Service Act of 1990. Specifically, an employer shall not displace an employee or position, including partial displacement such as reduction in hours, wages, or employment benefits, as a result of the employer using an AmeriCorps member; a service opportunity shall not be created that will infringe on the promotional opportunity of an employed individual; an AmeriCorps member shall not perform any services or duties or engage in activities that (1) would otherwise be performed by an employee as part of the employee’s assigned duties; (2) will supplant the hiring of employed workers; (3) are services or duties with respect to which an individual has recall rights pursuant to a collective bargaining agreement or applicable personnel procedures; or (4) have been performed by or were assigned to any presently employed worker, an employee who recently resigned or was discharged, an employee who is on leave, an employee who is on strike or is being locked out, or an employee who is subject to a reduction in force or has recall rights subject to a collective bargaining agreement or applicable personnel procedure.

Will comply with the ineligible service provisions found in the Act. Specifically, a program may not use AmeriCorps members to perform service that provides direct benefit to any (1) business organized for profit; (2) labor union; (3) partisan political organization; (4) organization engaged in religious activities (unless such service does not involve the use of members to give religious instruction, conduct worship services, provide instruction as part of a program that includes mandatory religious education or worship, construct or operate facilities devoted to religious instruction or worship, or engage in any form of proselytization; or (5) nonprofit organization that fails to comply with the restrictions contained in section 501 (c)(3) of the Internal Revenue code.

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Will comply with all Prohibited Activities related to AmeriCorps Member service.

By signing below, we certify that we have read and agree to perform all actions and support all intentions in the Acknowledgement, Certification and Assurances sections above.

ORGANIZATION NAME:

EXECUTIVE DIRECTOR/ADMINISTRATOR NAME:____________________________________________SIGNATURE: DATE:

DESIGNATED HOST SITE SUPERVISOR NAME:______________________________________________SIGNATURE: DATE:

ILLINOIS PUBLIC HEALTH ASSOCIATION AMERICORPS PROGRAM HOST SITE APPLICATION QUESTIONSDIRECTIONS: Answering the following application questions will provide a clear and compelling justification for awarding the requested AmeriCorps member(s). Please answer each of the questions below completely and individually.

NEEDS AND SERVICES

1. Please describe the demographics of the population to be served.

2. How will the requested AmeriCorps Member’s activities meet the needs of the community that your organization serves? How were these needs identified? Include a description of any activities your organization is currently doing to address the identified community needs.

3. If your organization has previously served as an IPHA AmeriCorps Program Host Site, please describe any previous successes and how a new member will build upon those successes.

4. AmeriCorps Member service activities should not duplicate the routine functions of employees and cannot include those of displaced employees. Please describe how the AmeriCorps Member position is different from any current or previous employee functions.

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5. If applicable, how will the AmeriCorps member be involved in recruiting, training, and/or managing volunteers?

ORGANIZATIONAL CAPACITY

1. How will the AmeriCorps Member be incorporated into the existing organizational structure? Describe the plan for educating staff and community members about AmeriCorps and the member’s role in your organization.

2. The IPHA AmeriCorps Program requires each Host Site to have a designated Site Supervisor for the AmeriCorps Member. Among other duties, the person designated as the Site Supervisor will need to attend the Site Supervisor orientation, hold regular meetings with the AmeriCorps Member, complete required program forms, and maintain regular communication with the Program Director. Please explain why the person indicated on the application coversheet has been designated as the Host Site Supervisor. Describe the plan for member supervision.

3. Describe how your organization will provide support to the member in each of the following areas:a) Orientation: Provide a general outline of your orientation plan, including orientation to

your organization and the community.b) Training: List any training your organization will provide for the member. All host sites

are required to provide training on specific programs the member will be implementing. c) Professional Development: Describe the professional development opportunities

available to the member.

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4. IPHA will assist with the recruitment of AmeriCorps Members through the IPHA website, National AmeriCorps website, college and career websites, and other online community networks. If chosen as an IPHA AmeriCorps Host Site, how will your organization assist in the recruitment of your AmeriCorps Member(s)?

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I P H A A m e r i C o r p s M e m b e r P o s i t i o n D e s c r i p t i o n

By completing the template provided below, a position description will be developed for your organization’s requested AmeriCorps Member. The Position Description must detail the activities you anticipate your member executing throughout the term of service and the qualifications for this position. The document provided for you contains several items which are highlighted in yellow. Please replace all yellow text with your information and follow instructions for the Transportation Information section.

Position Focus : [Insert]

Host Site Information : [Organization Name, Address & Website]

Position Location : [Primary service location name and address, if different than organization location above]

Primary Responsibilities : [Task 1] [Task 2] [Task 3] [Task 4] [Task 5] [Continue bulleted list and insert additional tasks as needed] Complete and submit all necessary IPHA AmeriCorps paperwork and reports by pre-

determined deadlines. Attend all IPHA AmeriCorps trainings including orientation and team trainings. Complete all IPHA AmeriCorps required National Days of Service projects. Some local and out of town travel required.

IPHA AmeriCorps Position Requirements: 18 years of age or older by term of service start date. U.S. Citizen, U.S. National or lawful permanent resident. Possession of a high school diploma or equivalent, or commit to earning one prior to

receiving an education award. Complete Federal and State criminal background check and Sex Offender Registry

check (all provided and coordinated by IPHA AmeriCorps Program) Valid Driver’s License and proof of insurance; or valid State ID Regular and reliable attendance. Ability to commit to the full term of service.

Host Site Preferred Qualifications : [Qualification 1] [Qualification 2] [Qualification 3] [Qualification 4] [Continue bulleted list and insert additional qualifications as needed]

Transportation Information : [please delete all that do not apply] Position location is accessible by public transportation. Position location is not accessible by public transportation. Personal vehicle is recommended to get to position location. Personal vehicle is required to get to position location.

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Host Site organization vehicle is available for service activities. Member is covered by organization’s vehicle insurance policy.

Personal vehicle must be used for Host Site service activities. Mileage will be reimbursed by Host Site.

Monthly/annual public transportation passes are available for Host Site service activities and will be provided by the Host Site.

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